Current intraoperative storage and handling practices of autologous bypass conduit: A survey of the royal australasian college of surgeons

During bypass surgery for peripheral arterial occlusive disease and ischaemic heart disease, autologous graft conduit including great saphenous veins and radial arteries are frequently stored in solution. Endothelial damage adversely affects the performance and patency of autologous bypass grafts, and intraoperative graft storage solutions have been shown to influence this process. The distribution of storage solutions currently used amongst Cardiothoracic and Vascular Surgeons from Australia and New Zealand is not well defined in the literature. The aim of this study was to determine current practices regarding autologous graft storage and handling amongst this cohort of surgeons, and discuss their potential relevance in the context of early graft failure. From this survey, the most frequently used storage solutions were heparinized saline for great saphenous veins, and pH-buffered solutions for radial arteries. Duration of storage was 30–45 min for almost half of respondents, although responses to this question were limited. Further research is required to investigate whether ischaemic endothelial injury generates a prothrombotic state, whether different storage media can alter this state, and whether this is directly associated with clinical outcomes of interest such as early graft failure.

Brain stem death induces pro-inflammatory cytokine production and cardiac dysfunction in sheep model

Introduction

Organs procured following brain stem death (BSD) are the main source of organ grafts for transplantation. However, BSD is associated with inflammatory responses that may damage the organ and affect both the quantity and quality of organs available for transplant. Therefore, we aimed to investigate plasma and bronchoalveolar lavage (BAL) pro-inflammatory cytokine profiles and cardiovascular physiology in a clinically relevant 6-h ovine model of BSD.

Methods

Twelve healthy female sheep (37–42 Kg) were anaesthetized and mechanically ventilated prior to undergoing BSD induction and then monitored for 6 h. Plasma and BAL endothelin-1 and cytokines (IL-1β, 6, 8 and tumour necrosis factor alpha (TNF-α)) were assessed by ELISA. Differential white blood cell counts were performed. Cardiac function during BSD was also examined using echocardiography, and cardiac biomarkers (A-type natriuretic peptide and troponin I were measured in plasma.

Results

Plasma concentrations big ET-1, IL-6, IL-8, TNF-α and BAL IL-8 were significantly (p < 0.01) increased over baseline at 6 h post-BSD. Increased numbers of neutrophils were observed in the whole blood (3.1 × 10⁹ cells/L [95% confidence interval (CI) 2.06–4.14] vs. 6 × 10⁹ cells/L [95%CI 3.92–7.97]; p < 0.01) and BAL (4.5 × 10⁹ cells/L [95%CI 0.41–9.41] vs. 26 [95%CI 12.29–39.80]; p = 0.03) after 6 h of BSD induction vs baseline. A significant increase in ANP production (20.28 pM [95%CI 16.18–24.37] vs. 78.68 pM [95%CI 53.16–104.21]; p < 0.0001) and cTnI release (0.039 ng/mL vs. 4.26 [95%CI 2.69–5.83] ng/mL; p < 0.0001), associated with a significant reduction in heart contractile function, were observed between baseline and 6 h.

Conclusions

BSD induced systemic pro-inflammatory responses, characterized by increased neutrophil infiltration and cytokine production in the circulation and BAL fluid, and associated with reduced heart contractile function in ovine model of BSD.

Endothelin receptor antagonist improves donor lung function in an ex vivo perfusion system

BACKGROUND

A lung transplant is the last resort treatment for many patients with advanced lung disease. The majority of donated lungs come from donors following brain death (BD). The endothelin axis is upregulated in the blood and lung of the donor after BD resulting in systemic inflammation, lung damage and poor lung graft outcomes in the recipient. Tezosentan (endothelin receptor blocker) improves the pulmonary haemodynamic profile; however, it induces adverse effects on other organs at high doses. Application of ex vivo lung perfusion (EVLP) allows the development of organ-specific hormone resuscitation, to maximise and optimise the donor pool. Therefore, we investigate whether the combination of EVLP and tezosentan administration could improve the quality of donor lungs in a clinically relevant 6-h ovine model of brain stem death (BSD).

METHODS

After 6 h of BSD, lungs obtained from 12 sheep were divided into two groups, control and tezosentan-treated group, and cannulated for EVLP. The lungs were monitored for 6 h and lung perfusate and tissue samples were processed and analysed. Blood gas variables were measured in perfusate samples as well as total proteins and pro-inflammatory biomarkers, IL-6 and IL-8. Lung tissues were collected at the end of EVLP experiments for histology analysis and wet-dry weight ratio (a measure of oedema).

RESULTS

Our results showed a significant improvement in gas exchange [elevated partial pressure of oxygen (P = 0.02) and reduced partial pressure of carbon dioxide (P = 0.03)] in tezosentan-treated lungs compared to controls. However, the lungs hematoxylin-eosin staining histology results showed minimum lung injuries and there was no difference between both control and tezosentan-treated lungs. Similarly, IL-6 and IL-8 levels in lung perfusate showed no difference between control and tezosentan-treated lungs throughout the EVLP. Histological and tissue analysis showed a non-significant reduction in wet/dry weight ratio in tezosentan-treated lung tissues (P = 0.09) when compared to control.

CONCLUSIONS

These data indicate that administration of tezosentan could improve pulmonary gas exchange during EVLP.

Acquired von Willebrand syndrome in respiratory extracorporeal life support: a systematic review of the literature

BACKGROUND AND OBJECTIVE

Venovenous extracorporeal membrane oxygenation (VV ECMO) and extracorporeal CO2 removal (ECCO2R) are increasingly used in the management of severe respiratory failure. With bleeding complications being one of the major risks of these techniques, our aim in this systematic review was to assess the available literature on acquired von Willebrand syndrome (AvWS) and extracorporeal support. AvWS has previously been associated with bleeding and shear stress.

DESIGN AND DATA SOURCES

A systematic review, using Medline via PubMed, was performed to identify eligible studies up to January 2017.

RESULTS AND CONCLUSION

The prevalence of AvWF among patients on VV ECMO or ECCO2R is high, but only a limited number of studies are reported in the literature. AvWS testing should be performed, including vWF multimer analysis, vWF activity and vWF antigen concentration. The extent to which vWF contributes to bleeding during ECMO, or how much changes in ECMO management can influence high molecular weight vWF multimer levels, cannot be answered from the currently available evidence and there remains a need for future studies.

Biased signalling and proteinase-activated receptors (PARs): targeting inflammatory disease

Although it has been known since the 1960s that trypsin and chymotrypsin can mimic hormone action in tissues, it took until the 1990s to discover that serine proteinases can regulate cells by cleaving and activating a unique four-member family of GPCRs known as proteinase-activated receptors (PARs). PAR activation involves the proteolytic exposure of its N-terminal receptor sequence that folds back to function as a 'tethered' receptor-activating ligand (TL). A key N-terminal arginine in each of PARs 1 to 4 has been singled out as a target for cleavage by thrombin (PARs 1, 3 and 4), trypsin (PARs 2 and 4) or other proteases to unmask the TL that activates signalling via Gq , Gi or G12 /13 . Similarly, synthetic receptor-activating peptides, corresponding to the exposed 'TL sequences' (e.g. SFLLRN-, for PAR1 or SLIGRL- for PAR2) can, like proteinase activation, also drive signalling via Gq , Gi and G12 /13 , without requiring receptor cleavage. Recent data show, however, that distinct proteinase-revealed 'non-canonical' PAR tethered-ligand sequences and PAR-activating agonist and antagonist peptide analogues can induce 'biased' PAR signalling, for example, via G12 /13 -MAPKinase instead of Gq -calcium. This overview summarizes implications of this 'biased' signalling by PAR agonists and antagonists for the recognized roles the PARs play in inflammatory settings.

Pathway-selective antagonism of proteinase activated receptor 2

BACKGROUND AND PURPOSE

Proteinase activated receptor 2 (PAR2) is a GPCR associated with inflammation, metabolism and disease. Clues to understanding how to block PAR2 signalling associated with disease without inhibiting PAR2 activation in normal physiology could be provided by studies of biased signalling.

EXPERIMENTAL APPROACH

PAR2 ligand GB88 was profiled for PAR2 agonist and antagonist properties by several functional assays associated with intracellular G-protein-coupled signalling in vitro in three cell types and with PAR2-induced rat paw oedema in vivo.

KEY RESULTS

In HT29 cells, GB88 was a PAR2 antagonist in terms of Ca(2+) mobilization and PKC phosphorylation, but a PAR2 agonist in attenuating forskolin-induced cAMP accumulation, increasing ERK1/2 phosphorylation, RhoA activation, myosin phosphatase phosphorylation and actin filament rearrangement. In CHO-hPAR2 cells, GB88 inhibited Ca(2+) release, but activated G(i/o) and increased ERK1/2 phosphorylation. In human kidney tubule cells, GB88 inhibited cytokine secretion (IL6, IL8, GM-CSF, TNF-α) mediated by PAR2. A rat paw oedema induced by PAR2 agonists was also inhibited by orally administered GB88 and compared with effects of locally administered inhibitors of G-protein coupled pathways.

CONCLUSIONS AND IMPLICATIONS

GB88 is a biased antagonist of PAR2 that selectively inhibits PAR2/G(q/11)/Ca(2+)/PKC signalling, leading to anti-inflammatory activity in vivo, while being an agonist in activating three other PAR2-activated pathways (cAMP, ERK, Rho) in human cells. These findings highlight opportunities to design drugs to block specific PAR2-linked signalling pathways in disease, without blocking beneficial PAR2 signalling in normal physiology, and to dissect PAR2-associated mechanisms of disease in vivo.

Modulating human proteinase activated receptor 2 with a novel antagonist (GB88) and agonist (GB110)

BACKGROUND AND PURPOSE

Many cells express proteinase activated receptor 2 (PAR2) on their plasma membrane. PAR2 is activated by proteolytic enzymes, such as trypsin and tryptase that cleave the receptor N-terminus, inititating signalling to intracellular G proteins. Studies on PAR2 have relied heavily upon activating effects of proteases and peptide agonists that lack stability and bioavailability in vivo.

EXPERIMENTAL APPROACH

A novel small molecule agonist GB110 and an antagonist GB88 were characterized in vitro against trypsin, peptide agonists, PAR2 antibody, PAR1 agonists and flow cytometry,in seven cell lines using intracellular Ca(2+) mobilization and examined in vivo against PAR2- and PAR1-induced rat paw oedema.

KEY RESULTS

GB110 is a potent non-peptidic agonist activating PAR2-mediated Ca(2+) release in HT29 cells (EC(50) ∼200 nM) and six other human cell lines, inducing PAR2 internalization. GB88 is a unique PAR2 antagonist, inhibiting PAR2 activated Ca(2+) release (IC(50) ∼2 µM) induced by native (trypsin) or synthetic peptide and non-peptide agonists. GB88 was a competitive and surmountable antagonist of agonist 2f-LIGRLO-NH(2), a competitive but insurmountable antagonist of agonist GB110, and a non-competitive insurmountable antagonist of trypsin. GB88 was orally active and anti-inflammatory in vivo, inhibiting acute rat paw oedema elicited by agonist GB110 and proteolytic or peptide agonists of PAR2 but not by corresponding agonists of PAR1 or PAR4.

CONCLUSIONS AND IMPLICATIONS

The novel PAR2 agonist and antagonist modulate intracellular Ca(2+) and rat paw oedema, providing novel molecular tools for examining PAR2-mediated diseases.

Toward a 1550 nm InGaAs photoconductive switch for terahertz generation

We report a terahertz (THz) photoconductive switch made from a composite of metal ErAs nanoparticles embedded in In(0.53)Ga(0.47)As and coupled to a square spiral antenna. The THz output power was measured in a 77 K cryostat by using a standard hyperhemisphere-lens package, a Golay cell outside the cryostat, and a quasi-optical filter bank for spot frequency spectral measurements. Results indicate an average output power of approximately 12 microW at 22 V bias using 140 mW of optical pump power from a subpicosecond fiber mode-locked laser. In addition, the THz spectra displayed invariance to bias voltage despite operating near impact ionization.

Reflective terahertz imaging of porcine skin burns

A reflective pulsed terahertz imaging system based on direct detection was developed and used to obtain high-resolution images of a porcine skin specimen with superficial partial-thickness (second-degree) burns. Images were also obtained of the sample through ten layers of dry medical (cotton) gauze with minimal image degradation. The burned and unburned regions of skin had large differences in terahertz reflectivity, displaying clear delineation [20 dB signal-to-noise ratio (SNR) difference signal] between both regions in the images. The terahertz images also exhibited a "halo" surrounding the burn areas that may correlate to the extent of burn injury. The system operated at a center frequency of 500 GHz with 125 GHz of 3 dB bandwidth and used whiskbroom scanning to generate images with a spatial resolution of 1.5 mm. Each pixel was acquired with a 16 ms integration time, resulting in a 40 dB postdetection SNR. The simplicity and high SNR of the reflective terahertz system are promising steps toward real-time terahertz medical imaging.

Clinical experience with HLA-B7 plasmid DNA/lipid complex in advanced squamous cell carcinoma of the head and neck

OBJECTIVE

To investigate the safety and efficacy of alloantigen plasmid DNA therapy in patients with advanced head and neck squamous cell carcinoma using Allovectin-7 (Vical Inc, San Diego, Calif), a DNA/lipid complex designed to express the class I major histocompatibility complex antigen HLA-B7.

DESIGN

Multi-institutional prospective trial.

SETTING

Academic medical setting.

PATIENTS

A total of 69 patients were enrolled in 3 sequential clinical trials: a single-center phase 1 trial and 2 multicenter phase 2 trials. Eligibility criteria included unresectable squamous cell carcinoma that failed conventional therapy, Karnofsky performance status score of 70 or greater, and no concurrent anticancer or immunosuppressive therapies.

INTERVENTION

Patients received 2 biweekly intratumoral injections of 10 microg (phase 1 and first phase 2 trials) or 100 microg (second phase 2 trial) of Allovectin-7 followed by 4 weeks of observation. Patients with stable or responding disease after the observation period were given a second treatment cycle identical to the first.

MAIN OUTCOME MEASURES

Patients were assessed for toxic effects, and tumor size was measured after cycles 1 (at 6 weeks) and 2 (at 16 weeks).

RESULTS

Allovectin-7 treatment was well tolerated, with no grade 3 or 4 drug-related toxic effects. Of 69 patients treated, 23 (33%) had stable disease or a partial response after the first cycle of treatment and proceeded to the second cycle. After the second cycle, 6 patients had stable disease, 4 had a partial response, and 1 had a complete response. Responses persisted for 21 to 106 weeks.

CONCLUSIONS

Intratumoral plasmid DNA immunotherapy for head and neck cancer with Allovectin-7 is safe, and further investigations are planned in patients with less advanced disease, where it could potentially improve patient survival and reduce the need for radical high-morbidity treatments.

A unique microvascular phenotype shared by juvenile hemangiomas and human placenta

BACKGROUND

Juvenile hemangiomas are common, benign tumors, distinctive for their perinatal presentation, rapid growth during the first year of life, and subsequent involution. We recently reported that endothelia of hemangiomas highly express GLUT1, a glucose transporter normally restricted to endothelia with blood-tissue barrier function, as in brain and placenta.

OBJECTIVE

To investigate possible further similarities between hemangioma and placental vessels.

DESIGN

In a retrospective study of a variety of vascular tumors and anomalies, we assessed lesional immunoreactivities for the placenta-associated vascular antigens FcgammaRII, Lewis Y antigen (LeY), merosin, and GLUT1.

SETTING

A university-affiliated pediatric hospital.

MAIN OUTCOME MEASURE

Immunoreactivities scored for each antigen were summarized according to lesional type, compared with those of normal skin, brain, and placenta, and correlated with patient age, sex, and lesional location.

RESULTS

All of 66 hemangiomas (patients aged 22 days to 7 years) showed intense immunoreactivity for FcgammaRII, merosin, LeY, and GLUT1. No immunoreactivities for these markers were seen in any of 26 vascular malformations, 4 granulation tissue specimens, 13 pyogenic granulomas, or in the tumor vasculature of 6 malignant tumors of nonvascular origin. Microvascular immunoreactivity for all 4 markers was observed in placental chorionic villi, but was absent in microvessels of normal skin and subcutis. Brain microvessels expressed only GLUT1 and merosin.

CONCLUSIONS

A distinct constellation of tissue-specific markers is uniquely coexpressed by hemangiomas and placental microvessels. These findings imply a unique relationship between hemangioma and the placenta and suggest new hypotheses concerning the origin of these tumors.

The submental island flap in head and neck reconstruction

BACKGROUND

The submental island flap (SIF) is a new alternative in the reconstruction of various head and neck defects. We present our preliminary experience in the use of this flap and describe the surgical technique.

METHODS

Nine patients underwent reconstruction with the SIF between January 1998 and July 1999. The SIF has been used for the reconstruction of the cervical esophageal stenosis in 2 patients, floor of mouth and tongue defects in 6 patients, and a hemilaryngectomy defect in 1 patient.

RESULTS

With the exception of one partial flap loss caused by arterial insufficiency, no flap failures were observed. All the donor site defects but one were closed primarily. One patient who underwent reconstruction of a hemilaryngectomy defect underwent revision surgery because of intractable hair growth on the transferred skin paddle. Marginal mandibular nerve function was intact in all the cases.

CONCLUSIONS

When combined with the reported experience of other surgeons, our preliminary experience showed that the SIF was an excellent alternative in the reconstruction of head and neck defects because of its reliability, versatility, and relative ease of application.

Intracranial extension of inverted papilloma: An unusual and potentially fatal complication

BACKGROUND

The purpose of this article is to define the outcome of intracranial extension of inverted papilloma and outline a rationale for management of this rare clinical presentation.

METHODS

A review of patients with intracranial extension of inverted papilloma reported in the literature (18 patients), or treated in our institution (3 patients ) was performed. The data of these 21 patients were consolidated with regard to clinical presentation, treatment, and outcome. Nine patients, including 1 of our cases, had coexisting squamous cell carcinoma and therefore were excluded from the analysis. Twelve patients with "pure" inverted papilloma formed the basis of this study.

RESULTS

The majority of patients (83%) with intracranial inverted papilloma had recurrent disease. Patients with extradural disease had a survival rate of 86% with an average follow-up of 4.4 years. Eighty-six percent of these survivors were treated with craniofacial resection. In contrast, 75% of patients with intradural inverted papilloma were dead of disease with an average follow-up of 9.3 months regardless of the treatment modality.

CONCLUSIONS

Intracranial extension of inverted papilloma is mostly associated with recurrent disease. Intracranial extradural inverted papilloma can be effectively controlled with craniofacial resection. Intracranial intradural involvement of inverted papilloma has a poor prognosis regardless of treatment. Aggressive treatment of intranasal inverted papilloma may be the most important factor in preventing intracranial presentation.

Management of the N(0) neck

Paramount among the challenges and controversies among the head and neck surgeon is the proper treatment of the N0 neck. Therapeutic intervention for the N0 neck usually involves any of two treatment modalities alone or in combination: surgery or radiation therapy. This article discusses the potential treatment strategies for possible subclinical neck metastasis and the rationale for their use on a site by site basis for head and neck primary tumors.

Neurotic effects of doxycycline sclerotherapy

A patient experienced phrenic nerve paralysis after doxycycline sclerotherapy for treatment of chylous fistula at our institution. The purpose of this study is to use physiologic testing to determine whether doxycycline is capable of inducing defects in neural function. A nonrandomized, controlled trial was performed with nerve-conduction studies to determine possible deleterious effects of doxycycline sclerotherapy. Thirty-eight CD rats were used and separated into four groups. Doxycycline was applied to the sciatic nerves of rats by either topical application directly on the nerve or by intraneural injection. Nerve-conduction studies were done before surgery and at 1,7, and 21 days after surgery. The results showed a statistically significant decrement in nerve-conduction velocity and strength of transmitted impulse in those nerves injected with doxycycline solution. Complete nerve block was seen frequently. This effect was not seen with topical application of doxycycline or normal saline solution or with intraneural injection of normal saline solution. This study demonstrates that doxycycline can induce a marked decrement in neural function when applied to the subepineural layers of the sciatic nerve in the rat. Therefore doxycycline sclerotherapy should be used with great caution in situations in which it could become exposed to nerves that have sustained surgical trauma.

Histologic effect of doxycycline sclerotherapy on rat femoral nerve

BACKGROUND

This study stems from an encounter with a phrenic nerve paralysis in a patient following doxycycline sclerotherapy for treatment of chylous fistula. The purpose of this study is to identify possible histologic evidence of doxycycline-induced nerve injury.

METHODS

The femoral nerves of CD rats were used as the in vivo animal model. The nerves were exposed to varying concentrations doxycycline and normal saline was the control. The nerves were studied at several time intervals using two different staining techniques.

RESULTS

The results suggest that topical doxycycline induces tissue reactions which are different from normal saline. These reactions include stimulation of a local giant cell inflammatory reaction and disruption of the myelin sheath.

CONCLUSIONS

Despite the fact that this study does not give physiologic evidence of neurotoxicity, the histologic results suggest that topical doxycycline may cause nerve damage directly or indirectly. We conclude that doxycycline should not be used for sclerotherapy where unprotected nerves are exposed to the agent until further physiologic tests are performed to prove its safety.

Management of congenital vascular lesions of the head and neck

Congenital vascular lesions are often misdiagnosed and, for the most part, left untreated. The absence of a uniformly accepted classification of these lesions and confusion over their natural history are partly responsible. A new classification of these lesions recognizes two distinct groups of lesions, hemangiomas and vascular malformations. Hemangiomas are usually not present at birth, proliferate during the first year of life, and then involute. In contrast, vascular malformations are always present at birth, never proliferate, and never involute. Knowledge of this classification system will facilitate the diagnosis of these lesions and lead to appropriate, individualized treatment.

Bilateral parotid neoplasms

In this case, the experts come out of the starting blocks disagreeing. One expert (Dr. Myers) does not routinely use FNA, relying instead on clinical signs to suspect a malignancy. the other physicians (Drs. Robbins and Suen) obtain an FNA for each parotid mass and use the information in counseling patients. MRI is an important preoperative tool for one physician (Dr. Suen). When faced with bilateral tumors, one approach is to stage the operations to avoid possible bilateral facial nerve injury (Dr. Myers). Other approaches include operating on the larger tumor first if both are benign, the malignant tumor first if one is benign and one malignant, and on both sides under the same anesthetic if both are malignant (Dr. Robbins). The other consultant agrees with this latter approach, with the exception being that in the case of bilateral benign tumors, he would operate on the smaller side first (Dr. Suen). Regarding the role for further surgery, one expert would reoperate if there were a suspicion for residual gross tumor on the facial nerve (Dr. Robbins). The others (Drs. Myers and Suen) agree that the positive margin likely reflects microscopic disease and further surgery is not warranted. Radiotherapy is recommended by all the experts. There is no proven role for chemotherapy. There is disagreement regarding whether the facial nerve should have been removed on the left side. Two experts (Drs. Myers and Suen) agree on peeling tumor off the nerve and following with radiotherapy. However, one physician (Dr. Robbins) believes that the facial nerve should have been removed.(ABSTRACT TRUNCATED AT 250 WORDS)

Sinusitis in bone marrow transplantation

Bone marrow transplantation has become a beneficial and curative technique used in treatment of patients with different hematologic conditions. It has become widely used at our institution for hematologic malignancies and certain resistant solid tumors. However, this treatment can result in immunosuppression, with an increased chance of infection. The purpose of this study was to review the causes of infections and determine the number of patients diagnosed with sinusitis. In the retrospective study, we evaluated the cases of bone marrow transplant patients for incidence and cause of fever. Sixty-eight percent of patients had fever after transplant; of these, 59% had fever of unknown origin. Only 1% of the patients with fever were diagnosed with sinusitis. In the evaluation of fever, sinusitis was not usually suspected and therefore was not included in the differential diagnosis. With such a high percentage of fever of unknown origin in this growing patient population, appropriate pretreatment evaluation of each case to rule out sinusitis should be considered.

Laser photocoagulation of superficial proliferating hemangiomas

Hemangiomas present at, or soon after birth, proliferate and eventually involute. In spite of this, children may suffer severe psychosocial trauma during the formative years of their lives, and, in a proportion of cases, a cosmetically unacceptable result is left at the end of involution. Since flashlamp pumped dye lasers have been shown to selectively destroy ectatic dermal vascular tissue through intact epidermis, 6 patients with very early superficial cutaneous hemangiomas were treated. All treated areas resolved completely and treatment was completed by 12 months. No complications were encountered apart from mild, temporary post-inflammatory hyperpigmentation which was seen in one patient. This, however, resolved completely within 3 months of treatment. Flashlamp pumped dye lasers are thus able to effect complete resolution of very superficial proliferating cutaneous hemangiomas in neonates and infants without the risk of scarring.

Salivary gland tumors

Salivary gland cancers continue to pose both diagnostic and treatment dilemmas. Over the past year, a great deal has been written concerning salivary gland tumors in children, fine needle aspiration for salivary gland neoplasms, prognostic factors, and pathologic evaluation and treatment. Some of the more important findings include imaging studies and approaches to the human immunodeficiency virus-positive patient with parotid enlargement, the molecular biology of salivary cancer, and the pitfalls of fine needle aspiration cytology. The necessity of facial nerve sacrifice in parotid surgery for malignancy is debated, and the classification of tumors is clarified.

Treatment of hemangiomas of the head and neck

Hemangiomas are a group of pediatric tumors that present at or soon after birth. Rapid proliferation is seen in the neonatal period, and may continue for the first year of life. Involution follows, and may last as long as 12 years. Since hemangiomas invariably involute, the vast majority have been left untreated. At least 10% to 20% of cases, however, will need active intervention, traditionally in the form of oral Prednisone. The frequent occurrence of life-threatening complications, permanent deformities, and irreversible psychosocial damage in spite of adequate steroid therapy necessitated a fresh look at the management of these lesions. Using recently developed laser technology alone or in combination with surgical excision, the authors have developed guidelines for safe intervention in all stages of the hemangioma cycle. Safe, active intervention in accordance with these guidelines offers an alternative to the more conservative approach previously advocated.

Prophylactic antibiotics for head and neck surgery with flap reconstruction

The leading cause of postoperative morbidity in patients undergoing major head and neck surgical procedures is postoperative infection. This prospective randomized multi-institutional clinical trial was designed to compare the effectiveness of clindamycin phosphate and high-dose cefazolin sodium therapy in preventing postoperative wound sepsis in patients undergoing contaminated head and neck surgical procedures in which flap reconstruction was required. Either clindamycin phosphate (900 mg) or cefazolin sodium (2 g) therapy was instituted intravenously prior to surgery and continued every 8 hours, for a total of 24 hours. The patients received postoperative follow-up, and the wounds were graded according to the worst condition observed. One hundred cases were evaluated. Fifty-one patients received clindamycin and 49 patients received high doses of cefazolin; wound infection developed in 10 patients (19.6%) and 11 patients (21.6%), respectively. This difference was not statistically significant. The average duration of surgery was approximately 8 hours for both the infected and the noninfected groups of patients. High-dose cefazolin and clindamycin have similar efficacy when administered prophylactically under these circumstances. Reconstruction with free vascularized tissue may aid in reducing postoperative wound infection.

Investigation of urinary transforming growth factor alpha levels as tumor markers in patients with advanced squamous cell carcinoma of the head and neck

The objective of this study was to determine whether transforming growth factor alpha (TGF alpha) levels could be used as nonspecific tumor markers in patients with advanced squamous cell carcinoma (SCC) of the head and neck. Fourteen patients with epidermoid carcinoma of the head and neck were followed with serial urine TGF alpha levels, and the results were compared with the extent of cancer and the course of the disease. Based on the findings of this study further research is necessary before urine TGF levels can be recommended as a routine screening test for SCC of the head and neck.

Treatment of oral cavity vascular malformations using the neodymium:YAG laser

Although rare, hemangiomas and lymphangiomas of the oral cavity are difficult management problems. Surgical resection is still commonly thought of by many when considering treatment. Several articles in 1986 reported good results using the neodymium:yttrium-aluminum-garnet laser for these lesions. Using this laser, we have treated six patients with hemangiomas or lymphangiomas of the oral cavity over the past 4 years. Although most patients have required several treatments, the response has been excellent overall. This report confirms the results of previous studies.

Lingual thyroid: unusual appearance on computed tomography

A patient with a lingual thyroid was found to have inhomogeneous contrast enhancement on CT, findings not previously reported. Operative and histologic examination revealed marked thyroiditis and goitrous changes, explaining the CT findings.

Nasal septal melanoma

The controversial issues on management of nasal septal melanoma center around the extent of pretreatment evaluation. Probably the minimum required is a chest radiograph, CBC, and liver function test (Dr. Westbrook). The use of bone scan and CT scans of brain, lungs, and abdomen (Drs. Suen and Medina) is controversial and of little yield. Aside from distant metastasis to the lung, liver, and brain, the regional metastatic spread pattern includes the nodal groups of the buccal, submental, and submandibular areas, with the possibility of bilateral involvement. All consultants agreed that the primary tumor should be treated with a wide local excision; however, there is no agreement as to the extent of nodal groups included in the nodal dissection. No consultant recommended primary septal reconstruction. The use of postoperative radiotherapy in high-dose fractions remains experimental, in the protocol research stage.

Preauricular approach to infratemporal fossa

We present an approach to the skull base that allows access to both the infratemporal fossa and the middle cranial fossa with minimal morbidity. This approach is different from most of the previously described approaches in that it uses a preauricular incision, preserves the facial nerve, and avoids the mastoid bone. It involves dividing the zygomatic arch and displacing it inferiorly, dividing the malar eminence (zygoma) and displacing it anteriorly, and cutting the coronoid process and retracting it superiorly with the attached temporalis muscle. Reconstruction is accomplished by using the temporalis muscle or a pericranial flap to cover the dura, a free fat graft to fill the space left by tumor excision, and by wiring the zygomatic arch and malar eminence into their original positions. Case reports of both benign and malignant lesions are presented.

Cisplatin sensitization to radiotherapy in stage IV squamous cell carcinoma of the head and neck. A follow-up report

Thirty-six patients with stage IV squamous cell carcinoma of the head and neck were treated with cisplatin (15 mg/m2), administered synchronously with high-dose radiation therapy. Of the original 36 patients, 26 are dead of disease. Although previous reports of an 88% response to this regimen were noted, the disease-free intervals in this 36-patient group were short. The interval of time between treatment and death ranged from two to 27 months, with an average survival time of 10.7 months. It appears that although cisplatin potentiation to radiation therapy offers an encouraging clinical response initially, persistent clinical regression of disease is unlikely. Further studies of cisplatin sensitization of radiation therapy vs radiation therapy alone and chemotherapy alone need to be performed before this regimen can be considered strong enough to stand on its own merits.

Laser therapy for T1 glottic carcinoma of the larynx

We treated 21 previously untreated T1 or tumor in situ squamous cell carcinomas of the true vocal cords by carbon dioxide laser excision. The mean follow-up was 42 months, with a range of 26 to 64 months. Recurrent vocal cord carcinomas, with an average interval to recurrence of 21 months developed in four patients. Three of the four recurrences involved the anterior portion of the true vocal cord, including the anterior commissure. One of the patients with recurrence was treated again with the laser, and the other three underwent radiotherapy. All four patients are alive and have retained their larynges. Laser excision of selected T1 and in situ carcinomas of the true vocal cords is a cost-effective and viable alternative to radiotherapy or more radical surgical therapy.

Complications of laser surgery for laryngeal papillomatosis

Carbon dioxide laser surgery has become the treatment of choice for laryngeal papillomatosis. The purpose of this study was to determine the type, incidence, and severity of complications that occur with laser microlaryngoscopy for a disease that often requires multiple operations. Forty patients with laryngeal papillomatosis underwent a total of 222 carbon dioxide laser laryngoscopies over the 6 1/2-year period from June 1977 through December 1983. The results showed that 13 patients sustained a total of 23 separate complications. Intraoperative complications consisted of one episode of bilateral pneumothorax and one episode of cervical subcutaneous emphysema, both associated with the use of jet ventilation anesthesia, and one episode of a loosened tooth in a child with carious teeth. The delayed complications consisted of 10 patients with anterior laryngeal webbing, 2 patients with posterior webbing, 6 patients with laryngeal edema or fibrosis, and one episode each of prolonged dysphagia and tracheal foreign body. No airway fires occurred. Only 2 of 28 patients who had 5 or fewer laser laryngoscopies developed complications, but 11 or 12 patients undergoing 6 or more laser operations had complications. In summary, although the incidence of life threatening complications was low, the occurrence of minor complications such as small anterior glottic webs and persistent edema was relatively high, especially in those patients who required multiple laser laryngoscopies.

Cisplatin potentiation of radiotherapy. Long-term follow-up

Thirty-three patients with inoperable squamous cell carcinoma of the head and neck were treated with cisplatin, 15 mg/sq m, administered synchronously with high-dose radiation therapy. Twenty-nine patients (88%) responded to the regimen; of these, 20 had complete regression of all disease. Eight of the 20 had a relapse in less than one year of their treatment. Among those patients who did not have a relapse, the follow-up period was short. It is concluded that a clinical regression response is more likely with this treatment regimen than with radiation therapy alone, and that that response may be a better palliation. Further study of this combination of treatment modalities is warranted.

Functional evaluation of the spinal accessory nerve after neck dissection

The pain and dysfunction associated with a loss of innervation by the spinal accessory nerve has motivated surgeons to modify the classic radical neck dissection. A prospective study of 109 patients who underwent either a radical neck dissection or a modification of it with preservation of the spinal accessory nerve revealed that those patients in whom the nerve, muscle, and vein were preserved had less dysfunction (30 percent) than those with nerve preservation only (50 percent) or classic radical neck dissection (60 percent). In addition, even when the functional disability was the same, there was less associated pain with nerve-sparing procedures. Furthermore, a large group of patients (40 percent) who underwent classic radical neck dissection had minimal disability. Given these results, a prospective study of recurrence data in these patients is indicated.

Analysis of disability resulting from treatment including radical neck dissection or modified neck dissection

A multiinstitutional study to define the impact of total treatment programs involving radical neck dissection (RND) and modified neck dissection (MND) on patients' permanent disability was undertaken. A total of 243 patient responses were included in the study. Comparative analyses between the treatment groups show no advantage of one surgical operation over the other in returning patients to their pretreatment employment status. Radiation therapy was identified as adding significantly to the patient's permanent disability.

Surgical management of advanced scalp cancer

A series of 53 advanced scalp cancer patients treated with surgery is presented. A review of these patients concludes: 1) local tumor growth--not distant metastasis--is the primary problem; 2) management is based on the tendency of a tumor to spread laterally early in its development with a deep invasion occurring later on; 3) when deep invasion occurs, radical excision and reconstruction is indicated to control the disease; 4) recurrence following adequate local therapy requires a change in treatment modality.

Thyroid lymphoma with adjacent nerve paralysis

Although local nerve invasion in thyroid lesions is most commonly found with anaplastic carcinoma, it does not rule out lymphoma. Open biopsy is most helpful in the diagnosis of lymphomas. Ultrastructural studies are often necessary for confirmation of the diagnosis. Differentiation between lymphoma and anaplastic carcinoma of the thyroid is very important since the treatment is substantially different and the prognosis is much better with lymphoma. To our knowledge, the case presented represents the first case of Horner's syndrome secondary to lymphoma that has been documented in the literature.

Intra-arterial cisplatin treatment of adenoid cystic carcinoma

Adenoid cystic carcinoma (ACC) is unique among salivary gland tumors in both its natural history and in its response to nonsurgical treatment methods (ie, radiation and chemotherapy). The chemotherapeutic agent, cisplatin, seems to be unique in its ability to affect ACC. It might be that ACCs of the minor salivary glands are especially vulnerable to the intra-arterial method of administering this drug, because there are accessible feeding vessels to most locations in which these tumors occur. We have treated four patients with advanced ACC with intra-arterial cisplatin. The responses suggest that this method may be a useful adjunct in the management of this tumor both as a preoperative and as a palliative measure.

Chemotherapy for salivary gland cancer

Salivary gland cancers are usually treated with surgery and irradiation; however, some of the aggressive salivary gland cancers recur or metastasize and are not amendable to treatment with further surgery or irradiation. Little is known about chemotherapy for these palliative situations because of the relatively scarcity of these cancers. The data in the literature has provided little clinical information because all salivary gland cancers are usually lumped together and/or multiple different drug combination are used. In an effort to arrive at a rational basis for recommending specific drug regimens for specific histologic types of salivary gland cancers, a two-part study was undertaken to determine which chemotherapy drugs seem to be effective or ineffective. One part was a literature review, and the second part was a survey of numerous institutions' experiences, including our own. A total of 85 cases of salivary gland cancers treated with chemotherapy were felt to be evaluable for this study. The overall response rate (complete and partial) was 42%. Although disease responded whether it was local, regional, or distant disease, there was a higher response rate in local-regional disease compared to distant metastases. Salivary gland cancers are definitely sensitive to chemotherapy drugs. This study reveals which drugs seem to be effective and provides some rational basis for future chemotherapy trials for salivary gland cancers.

Blastomycosis of the larynx

Blastomycosis is an uncommon fungal disease which may mimic carcinoma of the larynx. Physical examination may show a granular appearance early in the disease with progression to laryngeal fibrosis. Histologic examination usually shows pseudoepitheliomatous hyperplasia, microabscesses, and giant cells. The broad-based budding yeast organisms may be easily overlooked unless special stains are used. Two cases of laryngeal blastomycosis which were originally treated as carcinoma are reported.

Evaluation of the effectiveness of postoperative radiation therapy for the control of local disease

Although we agree that postoperative irradiation does improve the local and regional control, our findings indicate that the rate of control, especially local control, is somewhat less than 90 percent. Our data reveal a recurrence rate of 32.7 percent in advanced, stage III and IV, squamous cell carcinomas in the head and neck treated by surgery and postoperative irradiation; this rate may be even greater with longer follow-up. We recommend that surgeons avoid "close" surgical margins (less than 5 mm) when resecting primary cancers and not rely too heavily on radiation therapy to control residual subclinical disease. It appears that continued study is needed to establish the true efficacy of irradiation in the control of subclinical disease, and that local recurrence must be differentiated from regional recurrence when reporting these results.

Immunological skin testing and interpretation: a plea for uniformity

Immunological skin tests are one of the major methods used for the assessment of one's immune status. A review of the literature clearly reveals that there is no uniform methods for the administration and interpretation of skin tests. Without uniformity, it is obvious that data are not comparable. Contradictory conclusions may be reached from the same skin test data, depending upon the method of interpretation used. Precedent, rather than rationale, has often determined the method of interpretation. There are studies which suggest that slight induration or erythema, often considered negative, are significant immunologic events. The various methods of skin test administration and interpretation are reviewed. Recommendations for application and interpretation are presented so that uniformity may exist.

Treatment costs for patients with head and neck cancer

A national health program is inevitable if medical care costs continue to soar as they have in recent years. Those of us treating patients with cancer of the head and neck are aware that the costs are high, but many are not aware of the actual figures involved. In this study, five typical head and neck cancer patients were selected, and the costs incurred by these patients were calcualted. Both direct and indirect medical expenses were considered and are presented. In addition, we report the representative costs of various treatment modalities. An awareness of medical care costs plus appropriate consideration of them in the planning and administration of treatment may help to reduce health care expenses. If we do not control these costs, the government undoubtedly will.

Results of BCG adjuvant immunotherapy in 100 patients with epidermoid carcinoma of the head and neck

One hundred patients with advanced, recurrent, or metastatic squamous cell carcinoma of the head and neck were treated with chemotherapy and BCG as adjuvant immunotherapy. The overall response rate was 35 per cent, and the median duration of response was seventeen weeks. BCG does not prolong duration of remission or survival time.